Limb-salvage treatment versus amputation for osteosarcoma of the distal end of the femur. 1986

An innovative staged prosthetic lengthening reconstruction strategy for osteosarcoma-related leg discrepancy

Correction of leg length discrepancy (LLD) in skeletally mature patients with osteosarcoma was rarely reported and quite challenging. This study aimed to propose a treatment strategy of staged lengthening and reconstruction with a standard static prosthesis to address LLD and restore limb function. It also evaluated the effectiveness of the strategy in terms of leg lengthening, functional outcomes, and complications. The strategy for lengthening included three stages. In stage 1, the previous prosthesis was removed and an external fixator with a temporary rod-cement spacer was placed. In this stage, the external fixator was used to lengthen the limb to the appropriate length. In stage 2, the external fixator was removed and the old rod-cement spacer was replaced with a new one. In stage 3, the rod-cement spacer was removed and the standard static prosthesis was planted. Nine skeletally mature distal femoral osteosarcoma patients with unacceptable LLD were treated in our institution from 2019 to 2021. We performed a chart review on nine patients for the clinical and radiographic assessment of functional outcomes, LLD, and complications. The mean (range) leg lengthening was 7.3 cm (3.6-15.6). The mean (range) LLD of the lower limbs decreased from 7.6 cm (4.1-14.2) before the lengthening to 0.3 cm (- 0.3 to 2.1) at the final follow-up with statistical significance (P = 0.000). The mean (range) Musculoskeletal Tumor Society score improved from 30.3% (16.7%-53.3%) before the lengthening to 96.3% (86.7%-100%) at the final follow-up with statistical significance (P = 0.000). Three patients (33.3%) had a minor complication; none needed additional surgical intervention. In the short term, the current staged lengthening and reconstruction with standard static prosthesis provided satisfactory functional outcomes and LLD correction with few complications. The long-term effects of this method need further exploration.

[Application of three-dimensional printed customized prosthesis with preserved epiphysis and articular surface in the reconstruction of large bone defects in treatment of adolescent femoral malignant tumors]

OBJECTIVE

To investigate the clinical application and effectiveness of three-dimensional (3D) printed customized prosthesis with preserved epiphysis and articular surface in the reconstruction of large bone defects in treatment of adolescent femoral malignant tumors.

METHODS

The clinical data of 10 adolescent patients with femoral primary malignant tumor who met the selection criteria and underwent limb salvage surgery with 3D printed customized prosthesis with preserved epiphysis and articular surface between January 2020 and October 2021 were retrospectively analyzed. There were 6 males and 4 females with an average age of 12.5 years ranging from 7 to 18 years. There were 8 cases of osteosarcoma and 2 cases of Ewing's sarcoma. Enneking stage was Ⅱb. The length of the lesions ranged from 76 to 240 mm, with an average of 138.0 mm. The length of osteotomy (i. e. length of customized prosthesis) ranged from 130 to 275 mm, with an average of 198.5 mm; the distance between distal osteotomy end and epiphyseal line ranged from 0 to 15 mm, with an average of 8.8 mm; the bone defect after osteotomy accounted for 37.36% to 79.02% of the total length of the lesion bone, with a mean of 49.43%. The operation time, intraoperative blood loss, complications, tumor outcome (refered to RESIST1.1 solid tumor efficacy evaluation criteria), and limb length discrepancy were recorded. The Musculoskeletal Cancer Society (MSTS) 93 score was used to evaluate the function at 6 months after operation, and visual analogue scale (VAS) score was used to evaluate the pain before and after operation.

RESULTS

The operation was successfully performed in all the 10 patients, and the postoperative pathological results were consistent with the preoperative pathological results. The operation time was 165-440 minutes, with an average of 263 minutes; and the intraoperative blood loss was 100-800 mL, with an average of 350 mL. All patients were followed up 7-26 months, with an average of 11.8 months. No tumor was found on the osteotomy surface; the customized prosthesis were firmly installed and closely matched with the retained articular surface. The tumor outcome of neoadjuvant chemotherapy was stable in 4 cases and partial remission in 6 cases. No local recurrence or distant metastasis was found in 9 cases after postoperative adjuvant chemotherapy; pulmonary metastasis was found in 1 case at 12 months after operation. Two patients had local incision fat liquefaction, superficial infection, and delayed healing at 14 days after operation; 1 patient had local bone absorption at the contact surface of the prosthesis, and the screw and prosthesis did not loosen at 7 months after operation; the other patients had good incision healing, with no infection, prosthesis loosening, fracture, or other complications. At 6 months after operation, the MSTS93 score was 19-28, with an average of 24.1; 8 cases were excellent and 2 cases were good. The VAS score was 0.9±1.0, which significantly improved when compared with before operation (5.9±1.0) ( t=23.717, P<0.001). The height of the patients increased by 1-12 cm, with an average of 4.6 cm. At last follow-up, 4 patients had limb length discrepancy, with a length difference of 1 cm in 2 cases and 2 cm in 2 cases.

CONCLUSION

The application of 3D printed customized prosthesis in the resection and reconstruction of adolescents femoral primary malignant tumors can achieve the purpose of preserving epiphysis and articular surface, and obtain good effectiveness.

Synthesis of Fe3O4/PDA Nanocomposites for Osteosarcoma Magnetic Resonance Imaging and Photothermal Therapy

Osteosarcomas commonly develop in the metaphysis of the long diaphysis, resulting in pronounced malignancy and high rates of early pulmonary metastasis. At present, osteosarcoma patients exhibit relatively poor survival rates owing these metastases and to the emergence of tumor chemoresistance. As such, there is an urgent need to identify other approaches to treating affected patients. Herein, we synthesized Fe₃O₄@PDA nanocomposites that exhibited excellent biocompatibility and low toxicity in human and animal model systems. The resultant nanoparticles were able to improve T2 magnetic resonance imaging and to enhance the signal-to-noise ratio associated with osteosarcoma tumors in animal models. Moreover, we were able to successfully leverage these Fe₃O₄@PDA particles as a photothermal agent capable of significantly inhibiting the growth of tumors and preventing their metastasis to the lung compartment. Together, these results highlight a novel therapeutic platform that has the potential to guide both the more effective diagnosis and treatment of osteosarcoma patients in clinical applications.

Survivorship, complications, and outcomes following distal femoral arthroplasty for non-neoplastic indications

Aims

Endoprosthetic reconstruction with a distal femoral arthroplasty (DFA) can be used to treat distal femoral bone loss from oncological and non-oncological causes. This study reports the short-term implant survivorship, complications, and risk factors for patients who underwent DFA for non-neoplastic indications.

Methods

We performed a retrospective review of 75 patients from a single institution who underwent DFA for non-neoplastic indications, including aseptic loosening or mechanical failure of a previous prosthesis (n = 25), periprosthetic joint infection (PJI) (n = 23), and native or periprosthetic distal femur fracture or nonunion (n = 27). Patients with less than 24 months’ follow-up were excluded. We collected patient demographic data, complications, and reoperations. Reoperation for implant failure was used to calculate implant survivorship.

Results

Overall one- and five-year implant survivorship was 87% and 76%, respectively. By indication for DFA, mechanical failure had one- and five-year implant survivorship of 92% and 68%, PJI of 91% and 72%, and distal femur fracture/nonunion of 78% and 70% (p = 0.618). A total of 37 patients (49%) experienced complications and 27 patients (36%) required one or more reoperation. PJI (n = 16, 21%), aseptic loosening (n = 9, 12%), and wound complications (n = 8, 11%) were the most common complications. Component revision (n = 10, 13.3%) and single-stage exchange for PJI (n = 9, 12.0 %) were the most common reoperations. Only younger age was significantly associated with increased complications (mean 67 years (SD 9.1)) with complication vs 71 years (SD 9.9) without complication; p = 0.048).

Conclusion

DFA is a viable option for distal femoral bone loss from a range of non-oncological causes, demonstrating acceptable short-term survivorship but with high overall complication rates.

Cite this article: Bone Jt Open 2022;3(3):173–181.

Primary Fibular Sarcomas: Do They Behave Differently? An Institutional Review of 14 Patients

Surgical resection with wide margins is pivotal for sarcoma treatment but achieving the same for fibular sarcomas is a surgical challenge. Thus, we decided to evaluate our own institutional database of primary fibular sarcomas for surgical treatment, margins and pattern of relapse. From July 2014 to October 2018, we identified fourteen patients with histologically confirmed fibular sarcomas. Limb salvage surgery (LSS) was performed in thirteen patients included in our study. One patient treated with definitive radiotherapy was excluded from final survival and functional analyses. The proximal third fibula was the most common site of involvement (85.7%). Osteosarcoma was the histological diagnosis in eight (57.1%) and Ewing's in the remaining six (42.9%). All patients with proximal fibular tumours underwent Malawer type II resection. Margins were reported as free in twelve and involved in one case. The mean follow-up period was 37.15 months. In the operated group (n = 13), distant relapse occurred in 3 patients, combined relapse in 1 patient and 10 patients are alive and disease free until the last follow-up. The Kaplan-Meier survival analyses revealed the EFS (event-free survival-local/distant relapse) probability as 72.7% at 24 months and 53% at the end of 42 months. The OS (overall survival) probability at 24 months was 75.5% and 57.5% at the end of 42 months. Although it is difficult to achieve conventional wide margins in fibular sarcomas, our results suggest no increased incidence of local recurrence rates as compared to sarcomas at other common sites as reported in literature. Our series helps in understanding site-specific behaviour of sarcomas while contributing to the available data.

Clinical Outcome of Free Vascularized Fibula Graft in the Surgical Treatment of Extremity Osteosarcoma

Objective

To determine the clinical outcome and complications associated with use of free vascularized fibular graft (FVFG) in the resection and reconstruction of extremity osteosarcoma (OS).

Methods

This is a retrospective study recruiting a consecutive series of 18 patients who had undergone resection of extremity OS between May 2009 and June 2017 in our clinic center. Reconstruction of the bone defect with FVFG was performed for each patient. Surgery‐related complications and time of bone union were recorded at the follow‐up visit. The functional outcome of the reconstructed limb was assessed with the musculoskeletal tumor society (MSTS) scoring system. Patients were further classified into low extremity group and upper extremity group according to the tumor location. The Student t‐test was used to compare the surgical outcome between the two subgroups.

Results

There were 11 males and seven females with an average age of 25.9 ± 14.2 years. The mean length of the bone resection was 11.9 ± 4.1 cm. The mean follow‐up duration was 3.1 ± 1.2 years. As for tumor location, six cases were located in the femur, five in the tibia, four in the humerus, two in the ulna, and one in the radius. All the patients had successful graft healing at an average of 4.9 months after surgery. At the 2‐year follow‐up, an excellent functional outcome was observed in 88.9% of the patients (n = 16). The mean score of MSTS was 27.0 ± 4.6. Screw loosening and autograft fracture were observed in one patient with femur tumor, who had a low MSTS score of 11. Besides, there were three cases with delayed incision healing. Patients with lower extremity OS were found to have significantly longer duration of hospital stay and more blood loss than those with upper extremity OS. The incidence of postoperative complication was higher in the lower extremity group but with marginal significance (0% vs 36.3%, P = 0.1). There was no significant difference regarding time to bone union and the functional outcome as indicated by MSTS score.

Conclusions

FVFG technique can be effectively applied to the reconstruction of bone defects after OS resection with satisfactory functional outcome and low incidence of complications.

Development of a Patient-Reported Outcome Instrument for Patients With Severe Lower Extremity Trauma (LIMB-Q): Protocol for a Multiphase Mixed Methods Study

Background

A current limitation in the care of patients with severe lower extremity traumatic injuries is the lack of a rigorously developed patient-reported outcome (PRO) instrument specific to lower extremity trauma patients.

Objective

This mixed methods protocol aims to describe phases I and II of the development of a PRO instrument for lower extremity trauma patients, following international PRO development guidelines.

Methods

The phase I study follows an interpretive description approach. Development of the PRO instrument begins with identifying the concepts that are important to patients, after which a preliminary conceptual framework is devised from a systematic literature review and used to generate an interview guide. Patients aged 18 years or above with limb-threatening lower extremity traumatic injuries resulting in reconstruction, amputation, or amputation after failed reconstruction will be recruited. The subjects will participate in semistructured, in-depth qualitative interviews to identify all important concepts of interest. The qualitative interview data will be coded with top-level domains, themes, and subthemes. The codes will then be utilized to refine the conceptual framework and generate preliminary items and a set of scales. The preliminary scales will be further refined via a process of conducting cognitive debriefing interviews with lower extremity trauma patients and soliciting expert opinions. Phase III will include a large-scale field test, using Rasch measurement theory to analyze the psychometric properties of the instrument; shortening and finalizing the scales; and determining the reliability, validity, and responsiveness of the instrument.

Results

Phases I and II of this study have been funded. Phase I of this study has been completed, and phase II began in January 2019 and is expected to be completed in November 2019. Phase III will begin following the completion of phase II.

Conclusions

This protocol describes the initial phases of development of a novel PRO instrument for use in lower extremity trauma patients.

International Registered Report Identifier (IRRID)

DERR1-10.2196/14397

Free fibula flap for lower limb salvage after tumour resection

Context:

Post-tumour resection lower limb salvage.

Aim/Introduction:

Resection of tumours of the femur and tibia around the knee and ankle joints results in large bony defects. Often arthrodesis is an alternative; in case, adequate functional motors cannot be preserved or due to economic constraints. Thus, in an immunocompromised patient, the vascularised fibula is the best form of reconstruction. The vascularised fibular flap (pedicled/free) can be used in combination with an allograft. We refer to such a combination reconstruction as ‘allocombo’. The vascularised fibular graft hypertrophies in due course of time, and till that period, the allograft provides the required mechanical strength to allow early ambulation.

Subjects and Methods:

A retrospective study of 24 cases of vascularised fibular graft for lower limb reconstruction was conducted from February 2003 to March 2014. The average defect size was 15.5 cm and the average length of fibula harvested was 24.35 cm. A total of 19 free fibular flaps and 5 pedicled fibula were done. Mean age was 26 years. Fibula was nestled in the allograft obtained from the tissue bank.

Results:

The mean follow-up time was 52 months. Free flap success rate was 96%. Successful healing was achieved at 45 ends (97.8%). Radiological evidence of union at osteotomy sites occurred at an average of 6.8 months. Eight patients eventually succumbed to disease. At the final follow-up, the mean Musculoskeletal Tumour Society functional score of the evaluable patients was 26 (range 20–30).

Conclusions:

Pedicled fibula is a good option if the defect is within 14 cm of the knee joint at the femoral end. The vessels have to curve around the fibular head, thus its removal improves the reach of the pedicle. The flap is easy to harvest with predictable vascular anatomy and it can provide a large amount of vascularised bone and skin paddle. It results in early ambulation, rehabilitation and reduced morbidity. We realised that fixation is easier and chances of vascular injury are less in free as compared to pedicled fibula.

Growing Without Pain: The Noninvasive Expandable Prosthesis is Boon for Children with Bone Cancer, as well as Their Surgeons!

BACKGROUND

Orthopedic oncology has evolved over the past few decades to favor limb salvage over amputations. The noninvasive expandable prosthesis can be lengthened with an externally applied magnetic field eliminating the pain, stiffness, as well as the risk of infection. We present the largest series in Indian experience with this implant over the last 8 years while analyzing its benefit to the surgeons and the patients, but are we able to justify the cost effectiveness?

MATERIALS AND METHODS

Eighteen implants were used in 16 patients with nonmetastatic primary bone sarcoma from May 2006 to June 2015. All implants were manufactured by Stanmore implants worldwide based in London, UK. Lengthening was done in the outpatient department during the followup visits using an external electromagnetic coil. The function was assessed using the musculoskeletal tumor society (MSTS) score.

RESULTS

The patients had a mean age of 10.25 years at the time of surgery. The mean followup was 49.56 months. Twelve patients are alive at a followup after surgery. The prostheses were lengthened by a mean of 31.64 mm and average lengthening per session was 4.18 mm. The mean MSTS score was 28.83. Two revisions for jammed mechanism and two patients had a successful two-stage revision for delayed infection.

CONCLUSION

The noninvasive expandable prosthesis is an ideal implant for children undergoing limb salvage surgery for bone sarcoma who are expected to have more than 3 cm of limb length discrepancy at maturity. The initial high cost compared to a minimally invasive expandable implant can be recovered as there is no additional cost of lengthening. The small amounts of lengthening at more frequent intervals is more physiological as compared with the minimally invasive type where more lengthening is done to minimize the number of procedures. While the functional and oncological outcomes are comparable, this implant allows limb lengths to be maintained without pain, functional compromise or risk of infection.

Limb Salvage Versus Amputation in Conventional Appendicular Osteosarcoma: a Systematic Review

The overall survivorship in patients with appendicular osteosarcoma has increased in the past few decades. However, controversies and questions about performing an amputation or a limb salvage procedure still remain. Using three peer-reviewed library databases, a systematic review of the literature was performed to evaluate all studies that have evaluated the outcomes of appendicular osteosarcoma, either with limb salvage or amputation. The mean 5-year overall survivorship was 62% for salvage and 58% for amputation (p > 0.05). At mean 6-year follow-up, the local recurrence rates were 8.2% for salvage and 3.0% for amputation (p > 0.05). Additionally, at mean 6-year follow-up, the rate for metastasis was 33% for salvage and 38% for amputation (p > 0.05). The revision rates were higher with salvage (31 vs. 28%), and there were more complications in the salvage groups (52 vs. 34%; p > 0.05). Despite the heterogeneity of studies available for review, we observed similar survival rates between the two procedures. Although there was no significant statistical difference between rates of recurrence and metastasis, the local recurrence rate and risk of complications were higher for limb salvage as compared to amputation. Cosmetic satisfaction is often higher with limb salvage, whereas long-term expense is higher with amputation. Overall, current literature supports limb salvage procedures when wide surgical margins can be achieved while still retaining a functional limb.

Methotrexate Free Chemotherapy and Limb Salvage Surgery for Paediatric Osteosarcoma in India

BACKGROUND

Osteosarcoma (OS) is the most common primary malignant tumor of bone. The survival of OS patients has steadily improved from <20% in the early 20th century to around 70% with current treatment. There are very few studies in pediatric OS from India analyzing various aspects of the disease. This study focuses on the clinical profile, treatment options, and their complications and survival outcomes in pediatric osteosarcoma (OS) patients.

MATERIALS AND METHODS

This was a retrospective observational study which included pediatric patients <14 years of age, with newly diagnosed OS confirmed by histological diagnosis. Medical records of all patients were reviewed for clinical profile, treatment data, surgical management, and treatment complications. Patients alive at the end of treatment were followed up and overall (OAS) and disease-free survival (DFS) were analyzed.

RESULTS

Sixty-two patients were diagnosed with OS during the study of whom 55 opted for treatment. Cisplatin, adriamycin, and ifosfamide (PAI) was offered as chemotherapy and was completed as planned in the majority of patients. Limb salvage surgery was performed in most patients (87%, n = 40). The local recurrence occurred in 7 patients. The 3 years overall survival for the cohort was 54.6% ± 7.8% and DFS was 43.4% ± 7.9%, with females and those with the localized disease having a significantly better DFS.

CONCLUSIONS

High dose methotrexate free chemotherapy can give good OAS in localized disease and LSS is feasible in most of the pediatric OS patients. However the modest DFS even for localized disease with PAI chemotherapy and extremely poor outcomes in the metastatic OS, demand further research and innovations in systemic therapy to improve outcomes.

A meta-analysis of randomized control trials of surgical methods with osteosarcoma outcomes

Background

Osteosarcoma is a high malignant neoplasm, and conflicting findings have been reported on the survival and function recovery of osteosarcoma patients experiencing limb salvage or amputation. In the present study, we compared limb salvage surgery (LSS) with amputation in clinical outcomes of osteosarcoma patients by a meta-analysis.

Methods

The survival rate of osteosarcoma patients was collected from research reports from CNKI, MEDLINE, EMBASE, the Cochrane Database, and Google Scholar till April 30, 2016. The quality of including articles was evaluated by two independent reviewers. Differences between patients undergoing limb salvage surgery and amputation were analyzed based on postoperative survival rates.

Results

Ten articles were included according to selection criteria. There were 1343 patients in total from these studies. Our results showed that there was no significant difference between limb salvage surgery and amputation according to local recurrence; however, patients with limb salvage surgery had a higher 5-year overall survival.

Conclusions

LSS results in higher 5-year survival rates and better survival, while not increasing the risk of local recurrence. This study provided more evidences to support limb salvage surgery as a considerable treatment of osteosarcoma patients.

LARS® band and tube for extensor mechanism reconstructions in proximal tibial modular endoprostheses after bone tumors

Wide tumor resections around the proximal tibia (pT) are related to compromised function and high complication rates. This retrospective study aims to present the technique employed as well as functional and surgical outcomes of patients undergoing a Ligament Advanced Reinforcement System (LARS®) reconstruction of the knee extensor apparatus after tumor resection and modular endoprosthetic reconstruction of the proximal tibia. Twenty-five patients who received an artificial ligament after pT resection (11 men and 14 women; mean age, 29years; range 11 to 75years, with a minimum follow-up of 24months) were analyzed regarding the ISOLS failure mode classification. Twenty patients received LARS® during primary surgery, five patients during a revision of a pT modular endoprosthesis. LARS® was available as a band or a tube. The mean extension lag was nine degrees (range, 0 to 30°), the mean flexion was 103° (range, 60 to 130°). The mean extension lag and active flexion in primary implanted LARS were 7.8° and 101° versus secondarily implanted 45° and 115° (p<0.0001; p=0.15). Eleven out of 14 primary implanted LARS® band/tubes (71%) did well with extension lag (0 to 10°). LARS® usage as a band or as a tube showed similar results. The estimated five-year survival of LARS® was 92%. The median survival of LARS® implanted primarily was better than in the case of secondary implantation (p=0.006). Extensor mechanism reconstruction by LARS® band or tube shows excellent function and satisfactory implant survival after primary reconstruction of the extensor mechanism after proximal tibia resection. We experienced no LARS® rupture for only mechanical reasons.

LEVEL OF EVIDENCE

Level IV retrospective study.

Tibial Growth Disturbance Following Distal Femoral Resection and Expandable Endoprosthetic Reconstruction

BACKGROUND

In growing children, an expandable endoprosthesis is commonly used after distal femoral resection to compensate for loss of the distal femoral physis. Our hypothesis was that such prostheses can affect proximal tibial growth, which would contribute to an overall leg-length discrepancy and cause angular deformity.

METHODS

Twenty-three skeletally immature patients underwent the placement of a distal femoral expandable endoprosthesis between 1994 and 2012. Tibial length, femoral length, and mechanical axis were measured radiographically to determine the growth rate.

RESULTS

No patient had radiographic evidence of injury to the proximal tibial physis at the time of surgery other than insertion of the tibial stem. Fifteen (65%) of the patients experienced less proximal tibial growth in the operative compared with the contralateral limb. In ten (43%) of the patients, the discrepancy progressively worsened, whereas in five (22%) of the patients, the discrepancy stabilized. Seven patients did not develop tibial length discrepancy, and one patient had overgrowth of the tibia. For the ten patients with progressive shortening, the proximal tibial physis grew an average of 4.0 mm less per year in the operative limb. Five (22%) of the patients had ≥ 20 mm of tibial length discrepancy at last follow-up. Three of these patients underwent contralateral tibial epiphysiodesis. Three patients required corrective surgery for angular deformity.

CONCLUSIONS

The tibial growth plate may not resume normal growth after implantation of a distal femoral prosthesis. Physeal bar resection, prosthesis revision, and contralateral tibial epiphysiodesis may be needed to address tibial growth abnormalities.

View-Angle Tilting and Slice-Encoding Metal Artifact Correction for Artifact Reduction in MRI: Experimental Sequence Optimization for Orthopaedic Tumor Endoprostheses and Clinical Application

BACKGROUND

MRI plays a major role in follow-up of patients with malignant bone tumors. However, after limb salvage surgery, orthopaedic tumor endoprostheses might cause significant metal-induced susceptibility artifacts.

PURPOSES

To evaluate the benefit of view-angle tilting (VAT) and slice-encoding metal artifact correction (SEMAC) for MRI of large-sized orthopaedic tumor endoprostheses in an experimental model and to demonstrate clinical benefits for assessment of periprosthetic soft tissue abnormalities.

METHODS

In an experimental setting, tumor endoprostheses (n=4) were scanned at 1.5T with three versions of optimized high-bandwidth turbo-spin-echo pulse sequences: (i) standard, (ii) VAT and (iii) combined VAT and SEMAC (VAT&SEMAC). Pulse sequences included coronal short-tau-inversion-recovery (STIR), coronal T1-weighted (w), transverse T1-w and T2-w TSE sequences. For clinical evaluation, VAT&SEMAC was compared to conventional metal artifact-reducing MR sequences (conventional MR) in n=25 patients with metal implants and clinical suspicion of tumor recurrence or infection. Diameters of artifacts were measured quantitatively. Qualitative parameters were assessed on a five-point scale (1=best, 5=worst): "image distortion", "artificial signal changes at the edges" and "diagnostic confidence". Imaging findings were correlated with pathology. T-tests and Wilcoxon-signed rank tests were used for statistical analyses.

RESULTS

The true size of the prostheses was overestimated on MRI (P<0.05). A significant reduction of artifacts was achieved by VAT (P<0.001) and VAT&SEMAC (P=0.003) compared to the standard group. Quantitative scores improved in the VAT and VAT&SEMAC group (P<0.05). On clinical MR images, artifact diameters were significantly reduced in the VAT&SEMAC-group as compared with the conventional-group (P<0.001). Distortion and artificial signal changes were reduced and diagnostic confidence improved (P<0.05). In two cases, tumor-recurrence, in ten cases infection and in thirteen cases other pathologies were diagnosed.

CONCLUSIONS

Significant reduction of metallic artifacts was achieved by VAT and SEMAC. Clinical results suggest, that these new techniques will be beneficial for detecting periprosthetic pathologies during postoperative follow-up.

Does a pathological fracture affect the prognosis in patients with osteosarcoma of the extremities?

Opinion remains divided as to whether the development of pathological fracture affects the prognosis of patients with an osteosarcoma of the extremities.

We conducted a comprehensive systematic review and meta-analysis of papers which reported the outcomes of osteosarcoma patients with and without a pathological fracture. There were eight eligible papers for final analysis which reported on 1713 patients, of whom 303 (17.7%) had a pathological fracture. The mean age for 1464 patients in six studies was 23.2 years old (2 to 82). The mean follow-up for 1481 patients in seven studies was 90.1 months (6 to 240).

The pooled estimates of local recurrence rates in osteosarcoma patients with and without pathological fractures were 14.4% (8.7 to 20.0) versus 11.4% (8.0 to 14.8). The pooled estimate of relative risk was 1.39 (0.89 to 2.20). The pooled estimates of five-year event-free survival rates in osteosarcoma patients with and without a pathological fracture were 49.3% (95% CI 43.6 to 54.9) versus 66.8% (95% CI 60.7 to 72.8). The pooled estimate of relative risk was 1.33 (1.12 to 1.59). There was no significant difference in the rate of local recurrence between patients who were treated by amputation or limb salvage.

The development of a pathological fracture is a negative prognostic indicator in osteosarcoma and is associated with a reduced five-year event-free survival and a possibly higher rate of local recurrence. Our findings suggest that there is no absolute indication for amputation, as similar rates of local recurrence can be achieved in patients who are carefully selected for limb salvage.

Cite this article: Bone Joint J 2014; 96-B:1396–1403

Intercalary reconstructions with vascularised fibula and allograft after tumour resection in the lower limb

Reconstruction with massive bone allograft and autologous vascularised fibula combines the structural strength of the allograft and the advantages of fibula's intrinsic blood supply. We retrospectively analysed the outcome of twelve patients (4 male, 8 female) who received reconstruction with massive bone allograft and autologous vascularised fibula after tumour resection in lower limb. Mean age was 17.8 years (range 11–31 years), with following primaries: Ewing's sarcoma (n = 6), osteosarcoma (n = 4), liposarcoma grade 2 (n = 1), and adamantinoma (n = 1). Mean followup was 38.7 months (median 25.7 months; range 2–88 months). Seven tumours were located in the femur and five in the tibia. The mean length of bone defect was 18.7 cm (range 15–25 cm). None of the grafts had to be removed, but there occurred four fractures, four nonunions, and two infections. Two patients developed donor side complication, in form of flexion deformity of the big toe. The event-free survival rate was 51% at two-year followup and 39% at three- and five-year followup. As the complications were manageable, and full weight bearing was achieved in all cases, we consider the combination of massive bone allograft and autologous vascularised fibula a stable and durable reconstruction method of the diaphysis of the lower limbs.

Limb salvage surgery in bone tumors: a retrospective study of 50 cases in a single center

Modular segmental replacement system (MSRS) is one of the options for Limb conservation surgery in bone tumors. The study analyses a single center experience of use of MSRS for limb conservation in cases of primary bone tumors. Retrospective analysis was done for a series of cases of limb salvage procedures done over a five year period. All Patients with bone tumors who underwent limb salvage procedures utilising MSRS prosthesis were included in the study. The patients' record were perused for pre operative staging; neoadjuvant therapy used, if any; surgical procedure done; follow-up for prosthesis related complications and overall survival achieved. Total of 50 cases studied,included 28 males and 22 females . Median age at diagnosis of 28 (10-73) years. Tumor localized in lower limb in 38 patients, and upper limb in 12 patients. Tumors were malignant in 28 patients (56 %) and benign in 22 (44 %). The most common diagnosis was osteosarcoma (21 patients (42 %)) . The median resection length was 15 cm (range 6-25). High grade tumors (grade 2a and 2b) was found in 27 of 29 cases(93.1 %) . 14 patients had prosthesis related complications. The mean follow-up was 5 years (range: 3-7). 42 patients of 50 were alive with the endoprosthesis at the last follow-up. Survival rate of prosthesis is 84 %. The modular segmental-replacement system prosthesis favoured by us in limb sparing surgery for bone tumors results in satisfactory results in terms of tumor control and limb function.

[Femur reconstruction using combined autologous fibula transfer and humeral allograft]

Wide resection far into the femoral metaphysis may be required to treat malignant bone tumors in the pediatric and adolescent patient population. Biological reconstruction using a free, vascularized fibular graft is a well-established surgical technique. A short remaining femoral medullary canal and a relatively small fibula diameter can make fixation of the vascularized bone transfer difficult. Stable fixation and short fusion times, however, can be achieved with the use of an additional humeral allograft and plate osteosynthesis.

The clinical value of combined use of MR imaging and multi-slice spiral CT in limb salvage surgery for orthopaedic oncology patients: initial experience in nine patients

Background

The purpose of this prospective study was to evaluate the value of the combined use of MR imaging and multi-slice spiral CT for limb salvage surgery in orthopaedic oncology patients.

Patients and methods

Nine consecutive patients with lower/upper limb malignant bone tumours (7 osteosarcomas and 2 chondrosarcomas) were treated with limb-salvaging procedures. Preoperative planning including determination of the osteotomy plane and diameters of the prosthesis was performed basing on the preoperative CT and MR images. The histopathology was performed as golden diagnostic criteria to evaluate the accuracy of CT and MR-based determination for tumour’s boundary.

Results

The tumour extension measured on MRI was consistent with the actual extension (P>0.05, paired Student’s t test), while the extension measured on CT imaging was less than the actual extension. The length, offset and alignment of the affected limb were reconstructed accurately after the operation. An excellent functional outcome was achieved in all patients.

Conclusions

In the present study, MRI was found to be superior to CT for determining the tumour extension, combined use of MRI and CT measurement provided high precision for the fit of the prosthesis and excellent functional results.

Total condylar unipolar expandable prosthesis for proximal tibia malignant bone tumors in early childhood

Wide resection and reconstruction of tumors of the proximal tibia in the pediatric population are challenging procedures. The use of hinged, expandable prostheses may cause early closure of the distal femoral growth plate, which may increase the risk of limb discrepancy already present in this population. Between 1991 and 2001, 2 girls and 1 boy, aged 6, 6, and 4 years, respectively, were diagnosed with osteosarcoma of the proximal tibia and treated with wide resection and reconstruction with a condylar unipolar expandable tibial prosthesis. A press-fitted technique was used for component insertion. All patients received neoadjuvant and adjuvant chemotherapy. Radiographic and functional follow-up took place at least once a year for a minimum of 4 years. Adequate pain control, limb-length equality, and acceptable function were obtained in all patients. One patient presented with significant range of motion reduction (0°- 30°) in the affected knee. Limb lengthening was performed as needed to maintain balanced limb length. All patients had a good Musculoskeletal Tumor Society category score. No complications occurred in terms of component loosening or infection. One patient died shortly after 4-year follow-up because of doxorubicin-induced leukemia. Currently used hinged, expandable prostheses can jeopardize the unaffected distal femoral growth plate. This article describes a technique of reconstruction that spares the distal femoral growth plate. Adequate limb length can be expected with acceptable functional outcome. However, it is imperative to keep in perspective the expectations of the physician, the physician's team, the patient, and the patient's family.

Evolving techniques in foot and ankle amputation

Multiple clinical pathways lead to lower extremity amputation, including trauma, dysvascular disease, congenital defects, and malignancy. However, the principles of successful amputation-careful preoperative planning, coordination of a multidisciplinary team, and good surgical technique-remain the same. Organized rehabilitation and properly selected prostheses are integral components of amputee care. In the civilian setting, amputation is usually performed as a planned therapy for an unsalvageable extremity, not as an emergency procedure. The partial loss of a lower limb often represents a major change in a person's life, but patients should be encouraged to approach amputation as the beginning of a new phase of life and not as the culmination of previous treatment failures.

Megaprosthesis versus Condyle-sparing intercalary allograft: distal femoral sarcoma

Although functionally appealing in preserving the native knee, the condyle-sparing intercalary allograft of the distal femur may be associated with a higher risk of tumor recurrence and endoprosthetic replacement for malignant distal femoral bone tumors. We therefore compared the risk of local tumor recurrence between patients in these two types of reconstruction groups. We retrospectively reviewed 85 patients (mean age, 22 years; range, 4-82 years), 38 (45%) of whom had a condyle-sparing allograft and 47 (55%) of whom had endoprostheses. The minimum followup for both groups was 2 years (mean, 7 years; range, 2-19 years). Local recurrences occurred in 11% (five of 47) of the patients having implants versus 18% (seven of 38) of the patients having allografts. Using time to local recurrence as an end point, the Kaplan-Meier survivorship of the implant group was similar to that of the condyle-sparing allograft group at 2, 5, and 10 years (93% versus 87% at 2 years, 87% versus 81% at 5 years, and 87% versus 81% at 10 years, respectively). The condyle-sparing allograft procedure offers the potential advantage of retaining the native knee in a young patient population while incurring no greater risk of local recurrence as those offered the endoprosthetic procedure.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Innovative trident fixation technique for allograft knee arthrodesis for high-grade osteosarcoma around the knee

OBJECTIVE

Reconstruction for osteosarcoma around the knee after wide resection faces the challenge of great bone defect and future limb length discrepancy in the skeletally immature patients. Modern prosthetic reconstruction may provide good results, but the longevity may be of concern and may not be affordable in certain communities. Allograft knee arthrodesis still has its role in light of bone stock preservation and cost-effectiveness.

METHODS

We developed the innovative trident fixation technique utilizing three Steinmann pins to minimize limb length inequality without jeopardizing knee fusion stability. Twelve patients were enrolled. The mean age was 11.5 (10-13) years. Two had high-grade osteosarcoma in proximal tibia and others in distal femur.

RESULTS

Two patients died of oncological disease. The median follow-up of the disease-free 10 patients was 47 (41-60) months. All allograft-host bone junctions healed uneventfully without major complications except one allograft fracture. The average limb length discrepancy was 1.45 (1.0-2.1) cm at latest follow-up.

CONCLUSIONS

This straightforward technique was successful in knee arthrodesis with minimized limb length inequality. Accordingly, in light of bone stock preservation and longevity for the young children, it may be a surgical alternative for malignant bone tumors around the knee.

Prognostic factors and outcomes for osteosarcoma: an international collaboration

We aimed to evaluate the prognostic significance of traditional clinical predictors in osteosarcoma through an international collaboration of 10 teams of investigators (2680 patients) who participated. In multivariate models the mortality risk increased with older age, presence of metastatic disease at diagnosis, development of local recurrence when the patient was first seen, use of amputation instead of limb salvage/wide resection, employment of unusual treatments, use of chemotherapeutic regimens other than anthracycline and platinum and use of methotrexate. It was also influenced by the site of the tumour. The risk of metastasis increased when metastatic disease was present at the time the patient was first seen and also increased with use of amputation or unusual treatment combinations or chemotherapy regimens not including anthracycline and platinum. Local recurrence risk was higher in older patients, in those who had local recurrence when first seen and when no anthracycline and platinum were used in chemotherapy. Results were similar when limited to patients seen after 1990 and treated with surgery plus combination chemotherapy. This large-scale international collaboration identifies strong predictors of major clinical outcomes in osteosarcoma.

Current concepts on the surgical and medical management of osteosarcoma

Although advances have been made in both surgical and medical management of patients with osteosarcoma, the overall survival of patients with osteosarcoma has remained constant, with no substantial improvement in the past 15 years. Advances in imaging have had a substantial impact on surgical planning and staging. These advances have, in turn, had a major impact on the surgeon's ability to perform limb-sparing surgery. Surgical techniques have improved in terms of instrumentation, modularity of implants and availability. Limb salvage has proven to be an acceptable method of treatment both with respect to oncologic and functional outcome in those patients where a wide resection may be achieved. The use of massive allografts has been largely replaced with the use of modern oncologic endoprostheses. Biologic targets that will enable new therapies to have maximum effect on tumor cells while minimizing toxicity to the host tissues need to be identified.

Free vascularized fibular graft salvage of complications of long-bone allograft after tumor reconstruction

BACKGROUND

Long-bone allograft reconstruction following tumor extirpation can be complicated by problems such as nonunion at the host-allograft junction, allograft fracture, or allograft infection. Free vascularized bone grafts can be used to address these complications. The purpose of the current study was to examine retrospectively the outcomes and complications following allograft reconstruction salvage with onlay vascularized fibular grafts.

METHODS

A tumor registry review was conducted to identify all patients who underwent a reconstruction with a vascularized fibular graft for allograft reconstruction complications following tumor resection (host-graft nonunion, allograft fracture, or allograft nonunion) in the last nineteen years. The records of these patients were analyzed for details regarding the neoplasms and the treatment thereof, details of the free vascularized fibular graft reconstruction, time to osseous union, functional outcome, and clinical outcome.

RESULTS

Thirty-three patients satisfied the criteria for this study. The involved bones were the femur (eighteen patients), tibia (eight), and humerus (seven). Osseous union was achieved in all patients at a mean of 7.7 months. The average duration of follow-up was seventy-three months. Twenty-three patients achieved a good or excellent functional outcome. Ultimately, seven patients had a failure of the allograft reconstruction, which resulted in limb loss in five of them. Postoperative complications were relatively common in this series.

CONCLUSIONS

Free vascularized fibular grafting is a useful adjunctive surgical treatment for nonunion, fracture, and infection of an intercalary allograft reconstruction in limb salvage surgery. It has, however, a high rate of associated complications often resulting in failure.